APPLICATION FOR DAY PROGRAM SERVICES


This is NOT an employment application.
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Additional Information that MUST be submitted by email or faxed to (573) 777 - 4802 (Attention: Day Program Admissions) to be considered:

o   Copy of Current Individual Support Plan and any addendums with all needed signatures
o   Copy of Current Immunization Records (Must contain Hepatitis B and Tetanus information)
o   Copy of current Medication Administration Record if not listed on application
o   Copy of physician’s orders regarding diet if applicable (lunch/snacks will be brought from home)
o   Copy of Seizure Protocol (If applicable)
o   Copy of any Functional Behavior Assessment completed in last two years (if applicable)
o   Copy of Behavior Support Plan (If applicable)

Note:  Before first day of attendance, copies of ALL physician orders for any medication that will be administered during day program hours, including all PRNs, must be provided.

New MAR must be provided on the first day attendance of each month as well as any updated physician orders before individual can attend.

All PRNs and any scheduled medications to be administered during day program hours will need to be provided at the beginning of each month in bubble packs.


For which day program are you applying? *
Individual's Name: *
Individual's Name:
Address: *
Address:
Phone: *
Phone:
Alternate Phone:
Alternate Phone:
Date of Birth: *
Date of Birth:
Which of the following best describes the current living arrangement? *
Do you have a legal guardian? *
Guardian Phone:
Guardian Phone:
Guardian alternate phone:
Guardian alternate phone:
Guardian fax:
Guardian fax:
Guardian address:
Guardian address:
Do you have a residential provider? *
DPM Phone:
DPM Phone:
DPM fax:
DPM fax:
DPM mailing address:
DPM mailing address:
Suppoprt Coordinator's phone:
Suppoprt Coordinator's phone:
Is the entire team in favor of day program participation?
Waiver?
Participation Choices: The team would like this individual to participate (check one)
MEDICAL INFORMATION
Primary care physician: *
Primary care physician:
Clinic phone:
Clinic phone:
Clinic fax:
Clinic fax:
Clinic address:
Clinic address:
Does this individual: (check all that apply):
Is this individual incontinent? *
MEDICAL CONDITIONS
Does this individual have Diabetes? *
If yes to previous question, how is the Diabetes controlled?
Does this individual have any history or seizures? *
Date of last known seizure:
Date of last known seizure:
Pharmacy phone: *
Pharmacy phone:
Pharmacy fax:
Pharmacy fax:
SUPPORT CONTACT INFORMATION
Who should we contact if the individual needs additional support or to leave early (illness/behavior/weather)? *
Who should we contact if the individual needs additional support or to leave early (illness/behavior/weather)?
In a true emergency, 911 is always called first.
Address: *
Address:
Phone: *
Phone:
Alternate phone:
Alternate phone:
Second contact:
Second contact:
Address:
Address:
Phone:
Phone:
Alternate phone:
Alternate phone:
Third contact:
Third contact:
Address:
Address:
Phone:
Phone:
Alternate phone:
Alternate phone:
LIST ORDER OF OTHER CONTACTS IN AN EMERGENCY SITUATION
First contact:
First contact:
Address:
Address:
Phone:
Phone:
Alternate phone:
Alternate phone:
Second contact:
Second contact:
Address:
Address:
Phone:
Phone:
Alternate phone:
Alternate phone:
Third contact:
Third contact:
Address:
Address:
Phone:
Phone:
Alternate phone:
Alternate phone:
Please verify that you have provided all of the required information before clicking submit. We are unable to process incomplete applications or applications submitted without emailing or faxing all of the necessary items noted at the top of this application.